Provider Demographics
NPI:1053424135
Name:STUTES, JUDITH KAY (PA-C PHYSICIAN ASST)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:KAY
Last Name:STUTES
Suffix:
Gender:F
Credentials:PA-C PHYSICIAN ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 BYERS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3684
Mailing Address - Country:US
Mailing Address - Phone:937-866-2494
Mailing Address - Fax:937-866-8494
Practice Address - Street 1:415 BYERS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342
Practice Address - Country:US
Practice Address - Phone:937-866-2494
Practice Address - Fax:937-866-8494
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085513Medicaid
OHH035010Medicare PIN